Comparison of three different options for immediate treatment of painful temporomandibular disorders: a randomized,controlled pilot trial

Objective: The purpose of this study was to compare the short-term effectiveness of three different types of immediate, non-pharmacological intervention for alleviation of the painful symptoms of temporomandibular disorders (TMD).

Material and methods: Thirty-six patients (mean age 41.6?±?16.7 years, 25 females) diagnosed with non-dysfunctional painful TMD received counselling and subsequently were randomly allocated to three treatment groups: patients in Group A received prefabricated oral splints with water-filled elastic pads (Aqualizer^®), those in Group B were provided with vacuum-formed co-polyester oral splints and those in Group C were given appointments to receive Michigan-type hard splints. Clinical examination was conducted, at baseline and after 2 weeks, by use of the RDC/TMD. Current pain intensity was determined by evaluation of graded chronic pain status (GCPS) on a numerical rating scale (NRS). Active maximum mouth opening without pain (AMMOP) was also measured. Paired sample t-tests and one-way analysis of variance with a significance level of p?≤?0.05 were conducted.

Results: After 2 weeks, overall mean current pain was reduced by 41.95% (p?p?p?=?0.56) and C (22.29%, p?=?0.26). After 2 weeks, current pain level for Group B was significantly lower than that for Group C (p?=?0.041). Overall, there was a statistically significant increase of AMMOP (p?=?0.01).

Conclusion: All therapeutic options were pain-reducing. The results from this study suggest that cost-effective and time-effective intervention of counselling combined with use of a vacuum-formed splint is a favourable option for initial, short-term treatment of painful TMD.     

Management of pain in TMD patients: Bio-oxidative ozone therapy versus occlusal splints

Objective: To compare the effects of bio-oxidative ozone application with occlusal splints in temporomandibular disorder (TMD) patients with pain.

Methods: Forty participants were selected after the diagnosis of TMD and randomly divided into two groups: ozone group (OG, n = 20) and occlusal splint group (OCSG, n = 20). Ozone was applied to patients three times per week, for a total of six sessions. Patients in the OCSG were instructed to use occlusal splints every night over a period of four weeks.

Results: Mandibular movements showed significant differences for the time factor in OG and OCSG. Pressure pain thresholds of the temporal and masseter muscles at follow-up were significantly higher in the OCSG group. Both treatments statistically decreased the visual analog scale (VAS) scores. However, no statistically significant difference was observed between groups after the application of treatments.

Discussion: Occlusal splint treatment is still the gold treatment modality for objective pain relief in patients with TMD pain.     

Correlation of splint therapy outcome with the electromyography of masticatory muscles in temporomandibular disorder with myofascial pain

Abstract

Objectives. The aim of this study was to assess the effect of occlusal splint therapy on the electromyographic amplitude records (μV) of masticatory muscles in temporomandibular disorder (TMD) with myofascial pain and to detect a possible existence of a relationship between this effect and the treatment outcome. Materials and methods. Forty patients (23 females and 17 males) having TMD with myofascial pain were included in this study. They were randomly divided into two equal groups (20 of each). The first group (A) was treated by occlusal splints for 6 months while the second group (B) acted as a control. A clinical assessment and surface electromyography (EMG) for the masticatory muscles were performed at the beginning of the study, then 6 months later. The collected data were statistically analyzed using paired t-test. The differences were considered significant at p < 0.05. Results. The results showed that 85% of group A either completely recovered (35%) or clinically improved (50%) while only 20% of group B had a spontaneous improvement. In group A, the means of the electromyographic amplitude records (μV) of the monitored muscles have decreased after 6 months. However, the decrease was statistically insignificant (p > 0.05) in the patients (15%) who had no clinical changes. In group B, the means of the muscles' records (μV) in the left side slightly increased while those of the right side slightly decreased. These changes were statistically insignificant (p > 0.05). Conclusions. Occlusal splint could eliminate or improve the signs and symptoms of TMD patients with myofascial pain. It reduces the electromyographic amplitude records (μV) of the masticatory muscles. The splint therapy outcome has a correlation with the electromyographic amplitude changes of the masticatory muscles.     

Role of psychosocial factors on treatment outcome of temporomandibular disorders

Objectives: The aim of this randomized controlled study was to investigate the effect of depressive and non-specific physical symptoms on treatment outcome of temporomandibular disorders (TMD).

Material and methods: Eighty TMD patients were randomly assigned to splint group (n?=?39) and control group (n?=?41). The patients were classified in terms of depressive and non-specific physical symptoms as normal, moderate or severe using Research Diagnostic Criteria for Temporomandibular Disorders Axis II protocol. The effect of depressive and non-specific physical symptoms on the intensity of facial pain, as measured with visual analogue scale (VAS) was estimated with linear mixed models. The patients’ subjective estimates of the effects of treatment and TMD symptom severity were inquired at 1-year follow-up.

Results: At baseline and during the follow-up there were no significant differences in VAS scores between patients in different Axis II subscales. According to the mixed linear regression, depressiveness or nonspecific physical symptoms separately were not significantly associated with the VAS during the study. The association of VAS with depressive (p?=?.073) and nonspecific physical symptoms (p?=?.088) approximated statistical significance. Patients with moderate or severe nonspecific physical symptoms (with pain items) at baseline had more frequently moderate, severe or intolerable TMD symptoms after the treatment compared to those who were classified in normal subgroup.

Conclusions: The present study gave some indication of a possible negative effect of depressive and nonspecific physical symptoms (with pain items) on TMD treatment response. However, the results should be regarded as preliminary, and further studies with larger sample size are needed to confirm the results.     

Efficacy of stabilisation splint treatment on temporomandibular disorders

Summary The evidence supporting the use of stabilisation splints in the treatment of temporomandibular disorders (TMD) is scarce and a need for well‐controlled studies exists. The aim of this randomised, controlled trial study was to assess the efficacy of stabilisation splint treatment on TMD. The sample consisted of 80 consecutive referred patients who were randomly assigned to the splint group (n = 39) and the control group (n = 41). Subjects in the splint group were treated with a stabilisation splint, whereas subjects in the control group did not receive any treatment except counselling and instructions for masticatory muscle exercises which were given also to the subjects in the splint group. Outcomes were visual analogue scale (VAS) on facial pain intensity and clinical findings for TMD which were measured at baseline and after 1‐month follow‐up. The differences in change between the groups were analysed using regression models. Facial pain decreased and most of the clinical TMD findings resolved in both of the groups. The differences in changes in VAS or clinical TMD findings between the groups were not statistically significant. The findings of this study did not show that stabilisation splint treatment in combination with counselling and masticatory muscle exercises has additional benefit in relieving facial pain and increasing the mobility of the mandible than counselling and masticatory muscle exercises alone in a short time‐interval.     

Efficacy of Appliance Therapy on Temporomandibular Disorder Related Facial Pain and Mandibular Mobility: A Randomized Controlled Study

There is limited evidence supporting the role of occlusal splints in Temporomandibular disorder (TMD) therapy. The aim of this randomized controlled clinical trial was to assess the efficacy of stabilization splint therapy on TMD related facial pain and mandibular mobility. The sample of study consisted of eighty consecutive patients diagnosed with TMD. Patients were randomly assigned into two groups: a splint group (n = 40) comprising of patients treated with stabilization splint, councelling and masticatory muscle exercises, and a control group (n = 40), comprising of patients treated with councelling and masticatory muscle exercises alone. Data from both the groups were collected at the beginning of the study and after a 6-month follow up. The outcome variables were visual analogue scale on facial pain intensity and clinical findings for TMD (anterior maximal opening, mandibular right laterotrusion, mandibular left laterotrusion, mandibular protrusion, and number of painful muscle sites). Changes within the splint and control groups (before treatment and 6 months after treatment) were analyzed using paired samples t test. Differences in change between the splint and control groups were analyzed using independent samples t-test. The level of significance was set at p < 0.05. Facial pain and number of painful muscle sites decreased, and the mandibular mobility increased significantly in both groups after treatment; however the differences in changes in VAS or clinical TMD findings between the two groups were not statistically significant. The findings of this study show that stabilization splint treatment in combination with counselling and masticatory muscle exercises has no additional benefit in relieving facial pain and increasing the mobility of the mandible than counselling and masticatory muscle exercises alone over a 6-months’ time interval.     

Approaching temporomandibular disorders from a new direction: a randomized controlled clinical trial of the TMDes ear system

TMDes (Registered Trademark of Ascentia Health, Inc., Rockford, Illinois), custom-fit ear inserts to aid in reducing temporomandibular disorder (TMD) pain, were evaluated in a prospective, three-month, open-label, three-arm, randomized, unblinded clinical trial, which included patients with TMD diagnoses (RDC/TMD) of myofascial pain, arthralgia, and/or disc displacement with reduction; and a screening VAS pain score of > 4. The three treatment groups included: TMDes (n = 60), stabilization splint (n = 64), and jaw exercise regimen (n = 28). The mean change in Craniomandibular Index (CMI) scores (reductions reflecting improvement) from baseline to one month were -27% (TMDes), -20% (stabilization splint), -12% (jaw exercise regimen), and from baseline to three months were -45%, -41%, -36%, reflecting statistically significant noninferiority (p = 0.0096) of the TMDes to the stabilization splint (primary efficacy endpoint). The TMDes produced significant (p < 0.0001) mean changes in VAS pain scores from baseline of -46% at one month and -58% at three months and demonstrated comparable efficacy and safety to the stabilization splint.     

Contact sensitivity reactions in the oral mucosa

In clinical practice, it is commonly assumed that occlusal splints have therapeutic value in the treatment of temporomandibular disorders (TMD), but the evidence based on randomized controlled trials is scarce. This study evaluated the short-term (10-week) efficacy of a stabilization splint in subjects with recurrent secondary otalgia and active TMD treatment need using a randomized, controlled, double-blind design. Thirty-six subjects were randomly allocated to the two treatment groups: the stabilization splint and the control splint group. After 10 weeks' treatment, the intensity of secondary otalgia, measured on a VAS scale (from 0 to 100 mm), decreased statistically significantly in the stabilization splint group (t 2.12; P 0.006), but not in the control group. Improvement in active TMD treatment need in subjects showing moderate or severe signs and symptoms of TMD was reported significantly more often in the stabilization splint group than in the control splint group (χ² 5.71; P .017). A statistically significant decrease in the Helkimo clinical dysfunction index was seen in the subjects with stabilization splint (Z -2.63; P .009), but not in the subjects with control splint. The results indicate that the use of a stabilization splint is beneficial with regard to secondary otalgia and active TMD treatment need.     

Efficacy of stabilisation splint treatment on facial pain – 1‐year follow‐up

The aim of this randomised controlled trial was to assess the efficacy of stabilisation splint treatment on TMD‐related facial pain during a 1‐year follow‐up. Eighty patients were randomly assigned to two groups: splint group (n = 39) and control group (n = 41). The patients in the splint group were treated with a stabilisation splint and received counselling and instructions for masticatory muscle exercises. The controls received only counselling and instructions for masticatory muscles exercises. The outcome variables were the change in the intensity of facial pain (as measured with visual analogue scale, VAS) as well as the patients' subjective estimate of treatment outcome. The differences in VAS changes between the groups were analysed using variance analysis and linear regression models. The VAS decreased in both groups, the difference between the groups being not statistically significant. The group status did not significantly associate with the decrease in VAS after adjustment for baseline VAS, gender, age, length of treatment and general health status. The only statistically significant predicting factor was the baseline VAS, which was also confirmed by the mixed‐effect linear model. After 1‐year follow‐up, 27·6% of the patients in the splint group and 37·5% of the patients in the control group reported ‘very good' treatment effects. The findings of this study did not show stabilisation splint treatment to be more effective in decreasing facial pain than masticatory muscle exercises and counselling alone in the treatment of TMD‐related facial pain over a 1‐year follow‐up.     

Long-term treatment outcome for adolescents with temporomandibular pain

Objectives: This study aims to evaluate long-term, self-perceived outcome in adulthood for individuals treated as adolescents for temporomandibular disorder (TMD) pain in two previous randomized controlled trials (RCTs).

Materials and methods: The study included 116 subjects (81% females) treated for frequent TMD pain in two separate RCTs 5–21 (M?=?14.8, SD =4.9) years previously. Treatment consisted of occlusal appliance (OA) (n?=?41, 35.3%) or relaxation training (RT) combined with information for the control (Co) group (n?=?50, 43.1%), both compared to non-responders receiving additional, sequential treatment (ST) in a crossover study (n?=?25, 21.6%). Participants answered a questionnaire on their experience of frequency and intensity of TMD pain impaired chewing capacity and daily social activities, help-seeking behaviour and treatment, general health, other pain, and depressive symptoms.

Results: Older participants reported lower levels of frequency and intensity of TMD pain, impairment, and depressive symptoms, as well as better general health. Females reported more frequent and more intense TMD pain, greater impairment and more often reported ‘other pain’ compared to males. Non-responders receiving ST experienced significantly more TMD, and other pain and higher impairment levels compared to other groups. Those treated with an OA had sought additional treatment significantly less often since the RCTs than ST and RT/Co-treated individuals.

Conclusions: Adolescents treated with OA showed somewhat better sustained improvement over the extended follow-up period than those treated with RT/Co. Non-responders to treatment and females exhibited a poorer outcome. These groups need particular attention and extended or different treatments to achieve a better long-term outcome.     

Clinical comparison between two different splint designs for temporomandibular disorder therapy

Objective. To compare splint therapy in temporomandibular disorder (TMD) patients using two splint designs. Material and methods. In a double-blind randomized parallel trial, 40 consenting patients were selected from the dental faculty pool of TMD patients. Two splint designs were produced: an ordinary stabilization (Michigan type) and a NTI (Nociceptiv trigeminal inhibition). The differences in splint design were not described to the patients. All patients were treated by one operator. A separate, blinded, examiner assessed joint and muscle tenderness by palpation and jaw opening prior to splint therapy, and after 2 and 6 weeks' and 3 months' splint use during night-time. The patients reported headache and TMD-related pain on a visual analog scale before and after splint use, and were asked to describe the comfort of the splint and invited to comment. Results. Thirty-eight patients with mainly myogenic problems were observed over 3 months. A reduction of muscle tenderness upon palpation and self-reported TMD-related pain and headache and an improved jaw opening was seen in both splint groups (p<0.05; paired t-test and Wilcoxon signed-ranks tests). There were no changes for TM joint tenderness upon palpation. No differences were noted between the two splint designs after 3 months for the chosen criteria of treatment efficacy (p>0.05; Mann-Whitney U-test). Conclusion. No differences in treatment efficacy were noted between the Michigan and the NTI splint types when compared over 3 months.     

Evaluation of the short-term effectiveness of education versus an occlusal splint for the treatment of myofascial pain of the jaw muscles

BackgroundThe authors conducted a clinical trial to compare the effectiveness of an education program with that of an occlusal splint in treating myofascial pain of the jaw muscles across a short period.MethodThe authors assigned 44 patients randomly to two treatment groups; 41 patients completed the study. The first group (four male, 19 female; mean [standard deviation {SD}] age, 31.4 [14.0] years) received information regarding the nature of temporomandibular disorder (TMD) and self-care measures, whereas the second group (five male, 13 female; mean [SD] age, 31.1 [8.8] years) received an occlusal splint. One of the authors evaluated each patient every three weeks during a three-month treatment period. Treatment outcomes included pain-free maximal mouth opening, spontaneous muscle pain, pain during chewing and headache.ResultsAfter three months, changes in spontaneous muscle pain differed significantly between the education and occlusal splint groups (P = .034; effect size = 0.33). Changes in pain-free maximal mouth opening did not differ significantly between groups (P = .528; effect size = 0.20). Changes of headache and pain on chewing did not differ significantly between groups (P ≥ .550, effect size ≤ 0.10).ConclusionsDuring a short period, education was slightly more effective than an occlusal splint delivered without education in reducing spontaneous muscle pain in patients with TMD. Pain-free mouth opening, headache and pain during chewing were not significantly different between the two treatments.     

Prevalence of clinical signs and pain symptoms of temporomandibular disorders and associated factors in adult Finns

Abstract

Objective: To assess the prevalence of clinical signs and pain symptoms of temporomandibular disorders (TMD) and associated factors in the Finnish adult population, as well as the association between self-reported TMD pain symptoms and clinical signs.

Material and methods: The sample consisted of 1577 Finnish adults who participated in the Health 2011 Survey (BRIF8901). Signs of TMD were assessed using clinical examination, and TMD pain symptoms were inquired using validated questions.

Results: Of the study subjects, 35% showed at least one sign of TMD, 8% reported weekly facial pain and 6% weekly pain when biting or jaw opening. According to logistic regression, female gender, poor general health and low level of education increased the risk for most TMD signs and TMD pain symptoms. Muscle or TMJ pain on palpation associated significantly with self-reported weekly facial pain or pain when biting or jaw opening.

Conclusion: Over a third of the population showed clinical signs of TMD and less than one-tenth reported TMD pain symptoms. An assessment of a patient’s general health needs to be a part of TMD diagnosis and treatment. The Finnish versions of the validated questions are applicable for screening of TMD pain.     

Efficacy of stabilisation splint therapy combined with non‐splint multimodal therapy for treating RDC/TMD axis I patients: a randomised controlled trial

Stabilisation splint therapy has long been thought to be effective for the management of temporomandibular disorders (TMD). However, the superiority of stabilisation splint therapy compared to other TMD treatments remains controversial. The aim of this study was to determine the efficacy of stabilisation splint therapy combined with non‐splint multimodal therapy for TMD. A total of 181 TMD participants were randomly allocated to a non‐splint multimodal therapy (NS) group (n = 85) or a non‐splint multimodal therapy plus stabilisation splint (NS+S) group (n = 96). Non‐splint multimodal therapy included self‐exercise of the jaw, cognitive–behavioural therapy, self‐management education and additional jaw manipulation. Three outcome measurements were used to assess treatment efficacy: mouth‐opening limitation, oro‐facial pain and temporomandibular joint sounds. A two‐factor repeated‐measures analysis of variance (anova ) was used to evaluate the efficacy of the two treatment modalities (NS vs. NS+S), and Scheffe's multiple comparison test was used to compare the treatment periods. Subgroup analyses were performed to disclose the splint effects for each TMD diagnostic group. All three parameters significantly decreased over time in both groups. However, there were no significant differences between the two treatment groups in the total comparison or subgroup analyses; an exception was the group with degenerative joint disease. No significant difference between the NS and NS+S treatment approaches was revealed in this study. Therefore, we conclude that the additional effects of stabilisation splint are not supported for patients with TMD during the application of multimodal therapy.     

Temporomandibular disorder treatment in a patient wearing removable prostheses: A case report

Aim: The purpose of this intervention was to treat the patient, a 51-year-old woman, who was wearing a maxillary denture and a mandibular bilateral distal-extension partial denture (both unfit) and was suffering from temporomandibular disorder (TMD).

Methodology: The treatment suggested was to construct a superior repositioning splint (SRS), and after remission of the symptomatology, fabricate new dentures.

Results: The occlusal splint was effective and the symptomatology ceased after about five months of treatment. The new dental prostheses were made and followed up for 10 years with no return of the pain.

Conclusions: SRS and subsequent construction of new dentures after remission of the symptomatology was an effective treatment for TMD in the case described.     

The potential etiologic factors influencing tinnitus intensity in patients with temporomandibular disorders

Objectives: To investigate the potential relationships between the intensity of tinnitus associated with temporomandibular disorders (TMD) and potential etiologic factors, including age, gender, freeway space, sleep bruxism (SB), joint clicking, and headache.

Methods: The sample was comprised of 90 patients without any hearing loss, as confirmed by otorhinolaryngology, who self-reported subjective tinnitus and simultaneous TMD, based on the Research Diagnostic Criteria for TMD (RDC/TMD).

Results: The results showed a positive, weak correlation between the intensity of tinnitus and age (r = 0.225, p = 0.033). The presence of SB and headache were seen in higher proportions in the present sample, at 75.5% (n = 68) and 66.6% (n = 60), respectively.

Conclusions: In a population of patients with subjective tinnitus and TMD, no significant associations were found between tinnitus intensity and age, freeway space, SB, clicking presence, and headache, though gender did show a weak correlation with tinnitus intensity.     

Sleep bruxism and myofascial temporomandibular disorders: A laboratory-based polysomnographic investigation

BackgroundMany dentists believe that sleep bruxism (SB) is a pathogenic factor in myofascial temporomandibular disorder (TMD), but almost all supportive data rely on patients' self-reports rather than on direct observation.MethodsThe authors administered a structured self-report interview to determine whether a large and well-characterized sample of patients with myofascial TMD (124 women) experienced SB more often than did matched control participants (46 women). The authors then used data from a two-night laboratory-based polysomnographic (PSG) study to determine whether the case participants exhibited more SB than the control participants.ResultsThe results of independent sample t tests and χ² analyses showed that, although self-reported rates of SB were significantly higher in case participants (55.3 percent) than in control participants (15.2 percent), PSG-based measures showed much lower and statistically similar rates of SB in the two groups (9.7 percent and 10.9 percent, respectively). Grinding noises were common in both case participants (59.7 percent) and control participants (78.3 percent).ConclusionsMost case participants did not exhibit SB, and the common belief that SB is a sufficient explanation for myofascial TMD should be abandoned.Clinical ImplicationsAlthough other reasons to consider treating SB may exist, misplaced concern about SB's sustaining or exacerbating a chronic myofascial TMD condition should not be used to justify SB treatment.     

Treatment outcome of supervised exercise,home exercise and bite splint therapy,respectively, in patients with symptomatic disc displacement with reduction: A randomised clinical trial

The best treatment strategy for disturbing temporomandibular clicking sounds is not known. The aim was to evaluate the effect of exercise and bite splint therapy, respectively, in patients with symptomatic disc displacement with reduction. The study was a randomised clinical trial of subjects with temporomandibular joint (TMJ) clicking sounds with a reported severity/intensity of ≥4 on a numerical rating scale (0-10) and signs fulfilling the Research Diagnostic Criteria (RDC/TMD) for disc displacement with reduction. Thirty subjects each were randomised to bite splint, home exercise, or supervised exercise programme at the clinic. Two examiners (authors), blinded to the treatment modality, examined the same subject at baseline and at a 3-month follow-up. Non-parametric statistical methods were applied for analyses. A P-value <.05 was considered statistically significant. The dropout rate was highest in the home exercise group. About 50% of the participants reported improvement of their TMJ sounds with no significant difference between treatments. In the supervised exercise and the bite splint groups, approximately 2/3 of the patients reported 30% or more improvement of their TMJ sounds and half reported 50% improvement or more. The supervised exercise group also showed reductions in TMD pain, neck disability, mood disturbances and somatisation. Jaw exercise programmes and bite splint treatments had positive effects on TMJ clicking. The supervised exercise programme had an additional effect on the subject's well-being and thus may help to encourage patient's empowerment and coping strategies.     

不同类型咬合板缓解TMD疼痛症状的研究

目的:研究松弛型咬合板和稳定型咬合板缓解颞下颌关节紊乱病(TMD)疼痛症状的疗效。方法:选择TMD患者68例(急性期30例,慢性期38例),每组又分两个亚组,分别戴用松弛型咬合板和稳定型咬合板,使用视觉模拟量表评价患者治疗前后疼痛强度的变化。结果:①戴咬合板后静息状态下急、慢性组患者疼痛指数均较戴咬合板前明显下降(P<0.05),两种咬合板缓解疼痛的程度无明显差异;②戴咬合板后功能状态下急、慢性组患者疼痛指数均较戴咬合板前明显下降(P<0.05),但急性组戴松弛型咬合板疼痛缓解程度更显著。结论:松弛型和稳定型咬合板能缓解TMD疼痛,松弛型咬合板缓解TMD急性患者疼痛症状更显著。     

The implementation of a decision-tree did not increase decision-making in patients with temporomandibular disorders in the public dental health service

Objective: Many patients with temporomandibular disorders (TMD) seem to go undetected within primary dental health care. Primarily we evaluated if the implemented intervention increased the clinical decision-making for TMD patients; secondarily we evaluated if other factors could be identified that predicted performed or recommended TMD treatment.

Material and Methods: This case–control study was carried out within the Public Dental Health service in Västerbotten County, Sweden. An intervention based on a decision-tree with three screening questions for TMD (3Q/TMD) was implemented during 2015 in four clinics and compared with the remaining county. A total of 400 individuals were selected—200 3Q-positives and 200 3Q-negatives. The 3Q/TMD consists of Q1—frequent jaw pain, Q2—frequent pain on function, and Q3—frequent catching and/or locking of jaw. The 3Q/TMD answers were analyzed in relation to TMD treatment and any TMD related decision that was collected from the digital dental records.

Results: The intervention did not increase the frequencies of traceable clinical decisions among patients with TMD.

Conclusions: Despite the implemented intervention aimed, the indicated undertreatment of patients with TMD remains. Future studies are still needed to gain a deeper understanding of the clinical decision-making process for TMD patients in general practice dentistry.